CQC report explained · a nursing home
What the CQC found at Chilton Croft Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Care and risk plans were not always current or consistent. Inspectors also found gaps in repositioning, catheter and oral care records, unclean suction machines, and some problems with medicines administration.
- Effective?
- Good
- This focused inspection did not assess or rate Effective.
- Caring?
- Good
- This focused inspection did not assess or rate Caring. Inspectors did observe people being treated with respect and dignity and received positive feedback about care.
- Responsive?
- Good
- This focused inspection did not assess or rate Responsive.
- Well-led?
- Requires improvement
- Leadership and clinical oversight were not stable. The home had no registered manager, several clinical leads had left, and governance checks did not always show whether actions had been completed.
What inspectors found, March 2023
Chilton Croft Nursing Home is rated Requires Improvement; safety and leadership problems remained, but the home improved from Inadequate and left special measures.
This was an unannounced focused inspection on 16 and 23 February 2023. Inspectors checked whether improvements had been made in Safe and Well-led. They reviewed records, observed care and spoke with people, relatives and staff.
The home had improved since its last inspection. There were more staff, better safeguarding arrangements, improved fire safety checks and infection control audits. People and relatives gave positive feedback, and inspectors saw people treated with respect and dignity.
Important problems remained. Care and risk plans were sometimes out of date or conflicted with each other. Checks on clinical equipment, repositioning, oral care and some medicines were not reliable. Leadership was not stable, there was no registered manager, and the home remained in breach of regulations about safe care and good governance.
The overall rating changed from Inadequate to Requires Improvement. The home is no longer in special measures, but CQC will continue to monitor it and has asked for an action plan.
More staff
The home had increased staffing in line with people's needs. Inspectors found enough staff available during the inspection, and staff said they had more time with residents.
“At the time of our inspection there were sufficient staff available to meet people's needs.” from the report
Respectful care
People and relatives gave positive feedback about the quality of care. Inspectors saw people treated respectfully and with dignity.
“We observed people being treated with respect and dignity.” from the report
Improved safeguarding
Safeguarding training had been refreshed and safeguarding was discussed regularly with staff. The home was no longer in breach of the safeguarding regulation.
“Staff had recently been provided with safeguarding refresher training.” from the report
Fire and infection arrangements
Fire risk assessments and personal emergency evacuation plans were in place. Monthly infection control audits had also been introduced, and the home was free from offensive odours.
“There were now detailed fire risk assessments, which covered all areas in the home.” from the report
Care plans and risk information
seriousSome care and risk plans were brief, out of date or inconsistent between records. This affected guidance about choking, catheters and pressure wounds.
“Not all had been updated to reflect current needs and some conflicted with the information available in nurses care planning records.” from the report
Clinical equipment
seriousTwo suction machines had not been cleaned after use, and there was no system to check their cleaning and maintenance. This could leave equipment unsafe in an emergency.
“We found two suction machines which had not been cleaned after use.” from the report
Records of essential care
seriousInspectors found gaps in repositioning, catheter care, shower support and daily arm exercises. Toothbrushes were mostly dry and toothpaste was not always available, so daily oral care could not be assured.
“We found the majority toothbrushes dry, a lack of toothpaste available and so were not assured people had been provided with daily oral care as required” from the report
Medicines
seriousSome time-specific medicines were given up to 45 minutes earlier than recorded times. Reasons for giving some as-needed medicines were not always recorded.
“We observed time specific medicines such as those for people diagnosed with Parkinson's were being administered on the day of our visit up to 45 minutes earlier” from the report
Unstable leadership
seriousThere was no registered manager, and three clinical leads had left within eight months. Inspectors said this did not provide stable management or consistent clinical oversight.
“The service did not have a manager registered with CQC as legally required.” from the report
Environmental infection risks
needs fixingSome light pull cords were dirty and bedside bumpers had cracked or perished surfaces. These problems had not been found through the home's audits.
“We found bedside bumpers in need of need of replacement due to perished/cracked surfaces which posed a risk of harbouring bacteria.” from the report
- 01How will you ensure that care and risk plans used by care staff are current and match the nurses' records?
- 02How often are suction machines and other clinical equipment cleaned, maintained and checked?
- 03What checks are now in place to make sure repositioning, catheter care, oral care and prescribed exercises are recorded?
- 04How do you ensure time-specific medicines are given at the correct time and that reasons for as-needed medicines are recorded?
- 05Who is providing clinical oversight while the home appoints and registers its manager?
This was a focused inspection of Safe and Well-led only; the other three key-question ratings were not assessed in this report. This explanation was written from the published report of 9 March 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2022
Rated Inadequate and placed in special measures; inspectors found serious risks involving care, staffing, safeguarding and management.
This was an unannounced focused inspection. Inspectors visited on 21 and 22 June and 6 July 2022, including daytime, evening and night shifts. They observed care, checked records and spoke with people, relatives and staff.
The home was rated Inadequate for Safe and Well-led. Inspectors found gaps in pressure wound prevention, fluid monitoring, night checks and medicines records. People were also at risk because night staffing and fire arrangements were not sufficient for their needs.
The home had not acted on several improvements promised after its previous Requires Improvement rating. The overall rating became Inadequate and the home was placed in special measures. CQC said it would continue monitoring and normally re-inspect within six months unless the provider's registration was cancelled.
Mental capacity
Inspectors found that the home was working within the principles of the Mental Capacity Act. Required authorisations were in place where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place” from the report
Staff checks
The home completed identity, criminal record and reference checks before newly appointed staff started work.
“Checks on staff suitability were undertaken on all new staff prior to their appointment.” from the report
Stable staff team
Some people and relatives valued the continuity of a stable staff team, although other feedback about staffing was negative.
“People benefited from a stable staff team and there was a clear process in place to check staff suitability before they started work.” from the report
Infection arrangements
Inspectors were assured about several COVID-19-related arrangements, including visitor controls, personal protective equipment, testing and outbreak management.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Pressure wounds and fluids
seriousRisk assessments were not always followed. Repositioning records had gaps of up to 12 hours, and fluid monitoring was ineffective, increasing the risk of harm.
“The failure to follow risk assessments and ensure that people were assisted to reposition at regular intervals placed people at increased risk of skin breakdown.” from the report
Night staffing
seriousOne nurse and two care staff were supporting 29 people at night, including people with complex needs. Staff said they could not always provide constant observation or respond promptly.
“At night we found that there was one nurse and two care staff to support 29 people.” from the report
Fire safety
seriousNight staff did not have the information and training needed to respond to a fire. Personal evacuation plans were not available to them.
“There was no access to written fire safety procedures for staff with steps they should take to ensure people's safety.” from the report
Safeguarding
seriousSafeguarding concerns were not always properly scrutinised, and ongoing investigations had not been formally notified to CQC. Inspectors said this placed people at risk of harm.
“This shortfalls in safeguarding processes placed people at risk of harm and is a breach of regulation 13 (Safeguarding)” from the report
Weak management checks
seriousAudits and governance systems did not identify or correct important problems. Earlier promised improvements had not been put into practice.
“The continued failure to understand assess, monitor and mitigate risks, to maintain accurate and fit for purpose care records with ongoing plans to ensure improvement of the service demonstrated a continued breach of Regulation 17” from the report
Medicines storage and records
seriousSome medicines were left in an unlocked room, and records did not always show clear instructions or that creams were given as prescribed.
“Prescribed medicines were not always stored safely which placed people at risk of harm.” from the report
- 01What has changed to make sure people at risk of pressure wounds are repositioned as planned, and that records are complete?
- 02How many staff, including nurses, are now working overnight, and how do you ensure people needing constant observation receive it?
- 03Where are the fire procedures and personal evacuation plans kept, and how are night staff trained to use them?
- 04How are medicines, including creams and thickeners, stored, recorded and given at the prescribed times?
- 05What independent checks now show that the improvements promised after this inspection have been completed?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 4 August 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Chilton Croft Nursing Home
7 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- March 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2022Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- June 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2018Goodstayed GoodSafe: GoodWell-led: Requires improvement
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015Inspected but not ratedCaring: Requires improvement
- April 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 24 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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